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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313618
Report Date: 07/18/2022
Date Signed: 07/20/2022 01:11:52 PM

Document Has Been Signed on 07/20/2022 01:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GORDON, JACQUELINEFACILITY NUMBER:
304313618
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Licensee Ms. Gordon, JacquelineTIME COMPLETED:
12:30 PM
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A Required 1 Year annual inspection and a Case Management (Licensee initiated) inspection for a change in capacity was conducted at the facility by Licensing Program Analyst (LPA), Desai, Ketki. LPA met with licensee Ms. Gordon, Jacqueline, there were no children present at the Family Child care home due to Summer break. Licensee has been a care provider for a Small Family child care home since 2020 qualifying her to be a Large Family child care provider.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are (2) adults (including the licensee) residing in the facility.

Licensee stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. She was reminded if changes to notify the licensing office.

Per Licensee, operation hours will be Monday to Friday, 9.00 AM to 3.00 PM, care and supervision shall be provided to children ages 18 months to 14 years of age.
Licensee has all the needed items for Toddler care in the home, along with the assistant.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of child proof gates and safety latches to prevent the children from entering the off-limit areas during operation hours. Licensee acknowledged the children may never enter the off-limit areas. Control of property was verified by LPA during today’s inspection via mortgage documents. Kitchen is open with safety locks installed on the cabinet handles and blocking their views with tall dining chairs making it inaccessible to children. Garage glass door is next to the day care activity room, it has a lock installed on the glass door, garage is on the lower level of the home. (1)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GORDON, JACQUELINE
FACILITY NUMBER: 304313618
VISIT DATE: 07/18/2022
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These is a two story home with 4 bedrooms, 4 1/2 bathrooms, living room, dining room, TV/Game room, Office, kitchen, laundry room, fenced front/side yard and no backyard. Garage is on the lower level of the home.

Licensee has designated living area (divided into two sections), dining area, half bathroom and fenced front yard for Day care activities . ( Dining area is the new added room on today's inspection for day care activities). The designated Day Care activity areas were observed to be spacious, well lighted with proper air flow . Children shall enter through the main door of the home, leading into the small passage , each of the Day care rooms are across each side. The rooms have been set up with age appropriate safe toys, activities, educational items for the children along with furniture for learning / dining activities including a designated refrigerator, storage cubbies and changing station.

The designated bathroom is located at the end of the passage area , next to the bedroom on the right side it was observed to be safe and free of hazardous items. There is a cabinet under the sink, with a safety latch. There is additional toddler toilet seat, step tool for children, and bathroom was clean.

Licensee uses cots with linens during nap time, all napping items are provided and washed by the Licensee, Children nap in these area. Day care area is safe and appropriate set up was observed.

Off Limit areas: Licensee has designated 4 Bedrooms/ 4 bathrooms/ TV/Game room/ Office room/ Kitchen/ Laundry room and Garage as off limits. There is a fire place in the day care room with an installed glass barrier. During inspection off limit rooms were closed and locked.



Per Licensee there are No Weapons or Firearms or Bodies of Water on the premises. There is one small pet dog, which remains in the off limit areas during hours of operation.

There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Home also has an installed Sprinkler system.

Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. (2)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GORDON, JACQUELINE
FACILITY NUMBER: 304313618
VISIT DATE: 07/18/2022
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Licensee does provides AM snacks to the enrolled children. Lunch is brought from home in a labeled containers and are stored in their individual cubbies.

All Toddler needed items : Diapers/ Pull ups are provided by Licensee.

LPA verified there is a working telephone service (cellular service ).



OUTDOOR PLAY AREA: Per Licensee, children use the fenced front yard for outdoor activities, it is shaded and completely fenced with artificial turf flooring. The front play yard is accessed from the newly added day care room through a glass door opening into the front yard. Outdoor area has several age appropriate outdoor toys and activities including age appropriate climbing structures.

The licensee does have a current roster of children in care and the 3 records were reviewed on today's inspection , LPA reviewed the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. The licensee holds a valid Pediatric CPR/First Aid certification is valid through March 2023 and has completed the required Mandated Reporter Child Abuse training.
Licensee also has conducted Emergency fire and earthquake drills, last drill conducted in February 2022.

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization's, Pediatric CPR/First Aid, and mandated reporter training.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf (3)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GORDON, JACQUELINE
FACILITY NUMBER: 304313618
VISIT DATE: 07/18/2022
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LPA reviewed with the following safe sleep best practices:
*Always place infants on their backs for sleeping
*Use only a tight-fitting sheet on the crib or play yard mattress
*Do not hang any items from the crib or above the crib
*Keep all items, including blankets, out of the crib or play yard
*Pacifiers may be used as long as they do not have items attached to them
*Infants should not be swaddled or have any items covering them while sleeping
*The temperature of the room should be comfortable enough for an adult to wear a T-shirt and not be too hot or too cold.

Per Licensee, care and supervision is provided to children ages 18 months and above.

OTHER INFORMATION AND FORMS PROVIDED:
Capacity Handout for a Large Family Child Care Home was provided and LIC 9150 was reviewed with the Licensee


LPA discussed the following items with the applicant Ms. Gordon, Jacqueline during the Exit interview:

Criminal Record statement: Facility Representative Ms. Gordon, Jacqueline was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

(4)
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GORDON, JACQUELINE
FACILITY NUMBER: 304313618
VISIT DATE: 07/18/2022
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Safe Sleep : LPA discussed the safe sleep regulations with Facility Licensee Ms. Gordon, Jacqueline & discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Facility Representative Ms. Gordon, Jacqueline importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.



Review of records to be maintained : LPA reviewed with Facility Representative the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. LIC 311D was given to the Licensee at the time of the Exit interview.

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

Subscribe to CCLD important information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important license-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The facility was complying with Title 22 Regulations at the time of inspection.

(5)

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GORDON, JACQUELINE
FACILITY NUMBER: 304313618
VISIT DATE: 07/18/2022
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Fire Clearance approved was received from New port Beach Fire Prevention Bureau, approving the home for a Large FCCH.

A license with the change in capacity for 14 children (Large Family Child care home) will be issued after final review, in the event additional requirements are needed, Licensee will be notified.


On today’s inspection the home was observed to have a safe, healthful and comfortable accommodation with furnishing and equipment’s.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

A copy of this report and Appeal rights were presented to the Licensee Ms. Gordon, Jacqueline

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Ketki Desai
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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